Diabetes and Oral Health Part 1 : Clinical Implications and Management.
© Juliette Reeves 2004
Abstract
Diabetes now affects 3% of the British population. It is estimated that between 1995 and 2025 the number of people with diabetes will increase by 42% in industrialised countries and by 170% in industrialising countries This article presents a Two Part overview of the condition and its treatment. Oral health considerations are included with recommendations for dental management protocols. The nutritional implications are assessed and new protocols discussed.
As a profession we are in a good position to detect undiagnosed systemic disease through changes in the oral tissues. Early detection remains the best strategy in avoiding diabetic complications. As a profession we are urged to keep our knowledge of this disease up to date and embrace a team approach in the management of the diabetic patient and their oral health.
Diabetes now affects about 3% of the British population (1). It is estimated that there are 1.4 million people in the UK today with diabetes and as many as one in five UK citizens could have diabetes without knowing, according to a study from Manchester Medical School (2). Diabetes UK claims that the average sufferer has had diabetes from between nine and 12 years before doctors diagnose the condition. Diabetes costs the NHS £5.2 billion per year – nine percent of its total budget. Approximately one million people with diabetes in the UK have non insulin dependent (Type II) diabetes, making it one of the most common conditions affecting older people in the UK today.
Key Words: Diabetes Type I and Type II, insulin, hypoglycaemia, patient management, pharmacological management, nutritional management, diabetes and oral health.
Diabetes
Diabetes can be classified into three main types.
Type 1 diabetes is the result of pancreatic B cell destruction. In time, this destruction usually leads to an absolute deficiency of insulin. .Early in the development of the disease insulin production by B cells may be adequate but slowing. Eventually, all people with Type 1 diabetes will require insulin.
Type 2 diabetes is the result of resistance to the action of insulin by target cells. This condition may also be complicated by insufficient insulin production along with the insulin resistance. Many people with Type 2 diabetes are able to improve their insulin activity with dietary changes, exercise, weight loss and/or oral medications. Some patients with Type 2 diabetes however, do require extra insulin to maintain good blood sugar control.
Gestational diabetes mellitus (GDM) is any high blood sugar diagnosis which is first recognized during pregnancy. It may be the case that undiagnosed diabetes existed before pregnancy, or that the hormones of pregnancy brought on high blood sugar for the first time. In either case, the diagnosis of diabetes during pregnancy is categorized as gestational diabetes.
Other specific types of diabetes are rare, but this category represents 8 different causes of altered glucose metabolism. These include: genetic defects of beta cells, genetic defects in insulin action, diseases of the pancreas, several endocrine diseases, drug or chemical injury to the pancreas, infectious diseases which attack the pancreas, rare immune disorders and other genetic syndromes sometimes associated with diabetes. Insulin may or may not be required to manage blood sugar levels in each of these underlying diseases. It depends on the body's ability to produce insulin, and the degree to which insulin resistance plays a role in the altered metabolism.
Management
There are many ways in which the diabetic patient is managed, the main objective being to keep blood glucose levels as normal as possible. This can be achieved by dietary management alone, diet and oral hypoglycaemic drugs or insulin injection.
Diet The main dietary advice given centres around meals at regular intervals containing high fibre and complex carbohydrates. Simple sugars and refined carbohydrates are to be avoided. See Part 2
Oral Hypoglycaemic Agents These drugs are used for the Type II non insulin dependant diabetic. They are used to augment the effect of dietary management and occur in the following forms;
Sulphonylureas: These act mainly by augmenting insulin secretion and so are only effective when some residual pancreatic beta cell activity present. Long acting sulphonylureas include chorpropamide and glibenclamide.
Biguanides Metaformin is the only available biguanide, which works mainly by decreasing gluconeogenesis and increasing peripheral use of glucose. It acts only in the presence of endogenous insulin and so therefore, is only used where some residual function of the pancreatic islet cells exists. Metaformin is usually used when diet and sulphonylureas have failed. It can be used alone or in conjunction with a sulphonylurea.
Other Agents such as Acarbose are used to delay the digestion of starch and sucrose and so delay the rise in blood glucose following a carbohydrate rich meal. It is sometimes used in the treatment of type II diabetes as well. Guar Gum can also be used to reduce post prandial plasma glucose concentrations, by retarding carbohydrate absorption.
Insulin Most doses are determined on an individual basis, gradually increasing the dose but avoiding hypoglycaemic reactions. There are 3 main types of insulin.
Short Acting or Soluble Insulin This has a rapid onset of action and so is particularly useful in diabetic emergencies. It can be given intravenously and intramuscularly as well as subcutaneously.
Intermediate Acting Insulin such as Isophane Insulin Injection or Insulin Zinc Suspension.
Long Acting Insulin This has slower onset and lasts for long periods, such as Human Ultratard.
Insulin Regimens
The regimen for each patient is designed individually depending on the type of insulin used. The most common regimens include:
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Short acting insulin mixed with Intermediate acting insulin, twice daily before meals.
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Short acting insulin mixed with Intermediate acting insulin , before breakfast and Short acting insulin before evening meal with Intermediate acting insulin at bed time.
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Short acting insulin three times daily (before breakfast, midday and evening meal). Intermediate acting insulin at bed time.
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Intermediate acting insulin with or without Short acting insulin once daily before breakfast or bed time (3).
Oral Health
As a profession we are in a good position to detect undiagnosed systemic disease through changes in the oral tissues. It is now widely recognised that diabetes can affect oral health in a number of ways.
Periodontal disease in a common problem in diabetics and is more severe in individuals who are not well controlled. The reason for the periodontal destruction is not clear. However, the alteration in host responses to periodontal pathogens accounts for the differences in periodontal destruction.
More gingival sites with bleeding on probing have been reported in poorly controlled diabetics than in well controlled or moderately controlled groups(4). Periodontitis is now considered the sixth most common complication of diabetes
mellitus (5).
Xerostomia is also a common feature in poorly controlled diabetics. The patient often presents with a smooth, red, shiny tongue and mucosa. In well controlled individuals, salivary gland function does not appear to be impaired.
Coronal caries can be a problem in the poorly controlled diabetic, which may also be exacerbated when xerostomia is present.
Infections especially candidiasis, are prevalent in diabetics with poor disease control. The evidence suggests an immunological defect with deficient leukocyte functions in addition to metabolic abnormality in diabetes as an increasingly convincing aetiology(6).
Chronic Periodontal Disease
According to recent research presented at an American Academy of Periodontology / National Institute of Dental and Craniofacial Research symposium on periodontal systemic connections, chronic periodontal disease may contribute to diabetes (7)
While it has been established that people with diabetes are more prone to developing periodontal disease, new research is suggesting that periodontal disease can cause bacteria to enter the bloodstream and activate cytokine production. It was suggested that this increased cytokine production may damage or destroy the Islets of Langerhans in the pancreas inducing type II diabetes, even in otherwise healthy individuals. The next step will be to perform clinical studies and intervention trials.
Type I Diabetes and Bone Loss
A piece of research published in the December 2003 issue of Diabetes Care has shown that early onset diabetes is associated with reduced bone density and low bone mass following adolescence.(8)
Professor Stephen Schneider from the University of Medicine and Dentistry, New Jersey explains that the osteopenia linked with diabetes appears to be associated with a decreased bone turnover due to impaired osteoblastic maturation and function.(9) Recent studies in diabetic animals has shown enhanced apoptosis of osteoblastic cells as bone cells have receptors for both insulin and IGF-1 (Insulin Growth Factor). In vitro, insulin has been shown to increase proliferation and function of osteoblasts and IGF-1 stimulates osteoblast maturation and function.
Poor glycaemic control therefore, appears to reduce IGF-1 levels and other bone markers in adolescents with type 1 diabetes(10), which may affect bone density. This new research suggests therefore, that adolescents with type 1 diabetes may be at increased risk of bone loss in later life, particularly if they are poorly controlled. As a profession we are well aware of the need to monitor the periodontal and oral health of our type 2 diabetic patients, however Professor Schneider suggests that teenagers with type 1 diabetes also need careful monitoring.
Clinical Management
It may be useful to offer diabetic patients a morning appointment, after breakfast and before the midday meal and insulin dose. Patients should be advised not to miss meals and to check their blood glucose level before attending their appointment. The dentist should not be afraid to test the patients glucose in the surgery using a glucometer prior to an invasive dental procedure. This can be particularly helpful if the patient is not controlling their blood glucose well or if the patient feels unwell. This may be symptomatic of anacute complication. Asking the patient a few questions regarding their blood sugar control or food intake prior to a procedure may also be helpful. TABLE
It is important to ensure that the blood glucose is less than 200 mg/dl prior to an invasive procedure. An ideal figure would be 120-180mg/dl (3-5mmol/l)(11) If the blood glucose exceeds 200 mg/dl, the white blood cells decrease in function (12). Deciding whether to utilize antibiotic prophylaxis before an invasive dental procedure should be made after medical consultation. Dental drugs such as aspirin and steroids must be avoided.(11).
Part Two looks at the nutritional influences in diabetes and reviews some of the latest research surrounding the dietary management of the diabetic patient.
References
1. www.diabetes.org.uk
2. Diabetes Care 2001 vol 24
3. Dental Practitioners Formulary pp285-293
4. Losche W, Karapetow F, Phol A, Phol C, Kocher T: Plasma lipid and blood glucose levels in patients with destructive periodontal disease. J Clin Periodontol. 2000 27(8):537-41
5. Loe H: Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 1993 16(1):329-34.
6. Varon F, Shipman LM: The role of the Dental Professional in Diabetes Care. JCDP 2002 1:2:1-14
7. www.perio.org
8.Liu EY, Wactawski-Wende J, Donahue RP, Dmochowski J, Hovey KM, Quattrin T. Does low bone mineral density start in post-teenage years in women with type 1 diabetes? Diabetes Care. 2003;26:2365-2369.
9.Shhneider S., Shapses S.A.: Link Between Diabetes and Osteoporosis. Medscape Diabetes & Endocrinology 5(2), 2003. © 2003 Medscape
10.Bouillon R, Bex M, Van Herck E, et al. Influence of age, sex, and insulin on osteoblast function: osteoblast dysfunction in diabetes mellitus. J Clin Endocrinol Metab. 1995;80:1194-1202.
11. Scully C, Cawson RA: Medical Problems in Dentistry.2002 4 th Ed Wright press pp285-288
12. Golden, SH; Peart-Vigilance, Camille; Kao, L; Brancati , FL ; Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999 22(9): 1408-1414.